DOI: 10.1002/jclp.

22789

RESEARCH ARTICLE

An illustration of collaborative care with a focus

on the role of fathers in Maudsley Anorexia
Nervosa Treatment for Adults (MANTRA)

Janet Treasure | Ulrike Schmidt | Carol Kan

Section of Eating Disorder, Department of

Psychological Medicine, Institute of
Psychiatry, Psychology, and Neuroscience,
King's College London, London, United
Kingdom
Correspondence
Janet Treasure, PO 59, The Basement, 103
Denmark Hill, King's College London, SE5
8BP, United Kingdom.
Email: janet.treasure@kcl.ac.uk
Abstract
The aim of this case study is to illustrate the importance of
collaborative care as part of Maudsley Anorexia Nervosa
Treatment for Adults (MANTRA). Mothers are often at the
foreground of providing support within the family. However,
fathers have the potential to play a profound role. In this
paper, we describe a patient with anorexia nervosa treated
with the MANTRA. The formulation of this case included
autistic spectrum traits in both the father and daughter
leading to social isolation. We describe how the family
members were engaged into treatment and how paternal
support was used to promote social connection and an
improved quality of life in the daughter. Some details of the
case have been altered to maintain confidentiality.

KEYWORDS
anorexia nervosa, collaborative approach, MANTRA, social con-
nection

1 | INTRODUCTION

Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) is one of the psychotherapeutic treatments
recommended for adults with anorexia nervosa in the recent NICE guidelines (National Institute for Health & Care
Excellence, 2017). In brief, it is a cognitive motivation‐based psychotherapy, aiming to increase patients' motivation
for change as well as their understanding of the tension between their wish to maintain the illness and their
motivation for change. In addition, this treatment aims to externalize the eating disorders, that is, to separate the
illness from the person. It is based on the cognitive interpersonal model and a key element involves strategies to
reduce social isolation with the first step improving relationships with close others. It has similar efficacy to the
other forms of psychotherapy tested, including cognitive behavioral therapy and specialist‐supportive clinical

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1404 | TREASURE ET AL.

management (Byrne et al., 2017; Schmidt et al., 2012, 2015) and there is evidence that suggests that MANTRA is
preferred by patients themselves (Lose et al., 2014).
MANTRA has similarities to guided self‐care in that it is centered around a therapy workbook which is used
collaboratively between patient and therapist (Schmidt & Treasure, 2018). However, the therapists need to have
specific skills to engage patients, work collaboratively with family members or other forms of social support, and
provide a formulation and guidance in working though the various modules. The standard therapeutic “dose” is 20
weekly sessions that can be increased in patients with a more severe form of illness. Sessions with the family are
offered as part of treatment. In this case illustration, we focus on the modules that relate to case formulation and
collaborative care, rather than the modules that work with the individual which have been described in a previous
case series (Wade, Treasure, & Schmidt, 2011). In particular, we focus on the potential benefit of increasing the
father's role in supporting recovery.
Parents are important role models for normal eating and healthy exercise (Lydecker & Grilo, 2017). A strong
father–daughter relationship may partially protect against the development of an eating disorder (Johnson, Cohen,
Kasen, & Brook, 2002). Fathers can also provide a safe haven from teasing and “fat talk” (Keery, Boutelle, van den
Berg, & Thompson, 2005) and moderate the extreme idealization of the thinness ideal (Agras, Bryson, Hammer, &
Kraemer, 2007). In general, they show less anxiety and overprotection as a reaction to the eating disorder than
mothers (Hibbs, Rhind, Leppanen, & Treasure, 2015; Kyriacou, Treasure, & Schmidt, 2008). Fathers, however,
provide less time with informal care‐giving activities, averaging 1 hr compared with 2.5 hr for mothers (Rhind et al.,
2016). In addition, fathers show less engagement with treatment. For example, fathers' attendance in family‐based
treatment sessions gradually diminishes over time (72% of sessions attended in total) and only a third of fathers
have attended all of the sessions (Hughes, Burton, le Grange, & Sawyer, 2017). However, several studies have
shown that a good relationship with the father improves the outcome from an eating disorder (e.g., Bulik, Sullivan,
Fear, & Pickering, 2000; Castro, Toro, & Cruz, 2000). Thus, failure to engage fathers is of concern as their child's
outcome is related to their level of attendance (Hughes et al., 2017). Small amounts of accommodating behavior,
such as submitting to eating disorder behaviors, from any family member, can adversely impact on the outcome
(Salerno et al., 2016). It is therefore important that there is a collaborative team approach to treatment with both
parents involved.
In the following case, we illustrate the importance of adding collaborative care–skills‐based learning to the
parent support module of the MANTRA. This specific module can have an important role by informing the family
about the nature of the illness and providing skills in communication and behavior change that can address eating
disorder‐related maintaining factors. The patient's name and some clinical details have been changed for reasons of
confidentiality.

2 | C A S E IL L U S T RA T I O N

2.1 | Presenting problem

Rose presented to the adult eating disorders clinic with a diagnosis of anorexia nervosa. She weighed 35 kg (77 lbs.),
her height was 160 cm (5' 3”), and her body mass index (BMI) was 13.5 kg/m2. Nearly a year earlier, she had fallen
and broken her arm. The X‐ray had shown osteoporosis and the fracture clinic had questioned the possibility of an
eating disorder. It took 6 months for an appointment at the child and adolescent mental health services (CAMHS)
specialist eating disorders clinic to be arranged. By that time Rose was 17 years old and was therefore referred
onto the adult eating disorders service.
Rose's eating problems started when she was 11 years old and her eating pattern became more rigid after a
lesson on healthy eating. Two years later, the school contacted her parents after she fainted at school while
exercising during lunch. The family took her to the general practitioner who suggested that this was a phase she
TREASURE ET AL. | 1405

FIGURE 1 Formulation letter addressed to Rose by her therapist

would grow out of and did not arrange a follow‐up. Her dietary restriction and over‐exercise, predominantly
solitary running, persisted.

2.2 | Client description

Rose was clingy to her mother when she started school and was in floods of tears most mornings. She had
difficulties with her peers and was not invited for overnight stays or parties. She did eventually make two friends,
but these friendships suddenly ended with no obvious trigger when she was 9 years old. As a result, Rose became
more isolated and turned her interest to her pet mice. She became fascinated by genetics and collected breeding
data, such as birth weight, hair color, and behavior.
1406 | TREASURE ET AL.

FIGURE 1 Continued
TREASURE ET AL. | 1407

FIGURE 1 Continued

Rose did well academically and was perfectionistic about her schoolwork and in caring for her pet mice. Any
changes to her regular routine, such as starting a new academic year or going on holidays, made her anxious.

2.3 | Initial management plan

Rose's protracted, severe, and untreated eating disorder and lifelong poor psychosocial function gave her a poor
prognosis. However, when the possible need for an intensive approach such as inpatient care was broached, Rose
was insistent that she would do her utmost to work as an outpatient. The first sessions focused building up a joint
understanding of the illness and trying to plan for change in nutrition using social support from her family to
facilitate this.
1408 | TREASURE ET AL.

F I G U R E 2 An outline of the predisposing, precipitating, and perpetuating factors which may have contributed
to Rose's eating disorder

F I G U R E 3 A collaborative diagrammatic formulation created by Rose and her therapist. The flower plot shows
the “soil” from which the anorexia nervosa (AN) develops in terms of temperamental traits and life events. There is
a focus on the positive aspects that the temperamental traits can bring to recovery and an additional focus on
connecting with others to get support
TREASURE ET AL. | 1409

2.4 | Case formulation

In MANTRA, letters addressed to the patient are used to improve the therapeutic alliance, share the clinical
formulation, and consolidate treatment gains. These letters have been found to have a positive impact on
engagement, treatment acceptability, and outcome (Allen et al., 2016). Below we give an example of a formulation
letter addressed to Rose (Figure 1). It was written early in treatment with the aim of engaging and motivating Rose
as she was ambivalent about treatment and her parents were also not highly motivated.
From the onset of MANTRA treatment, a formulation is developed. It is usually in a form which can be easily
shared with the family from sessions 1–8. Figure 2 outlines the key components within the formulation in the forms
of predisposing, precipitating, and perpetuating factors and Figure 3 illustrates the formulation jointly produced by
Rose and her therapist. There were several features in Rose's clinical history which suggested that she may have
autism spectrum disorder traits. From early childhood, Rose had demonstrated poor social functioning, anxiety, and
obsessive–compulsive traits. Her hobby, mice breeding, was possibly a form of a highly‐invested special interest.
Moreover, her father described himself as somewhat of a loner, with an interest in solitary activities such as long‐
distance running. He joked that his wife described him as “somewhere on the spectrum” in that she considered both
he and Rose might have autism spectrum disorder traits.
In the collaborative care module of MANTRA, the formulation focuses on interpersonal risk and maintaining
factors (Figure 4). This was discussed with the family in either separated or joint sessions. In Rose's case, a lack of a
joined‐up approach from the parents was identified. Both her father and mother demonstrated some of the
common interpersonal reactions that occur when living close to the illness. First, close others often develop high
levels of negative expressed emotion, including anxiety‐related overprotection and/or frustration fueled hostility/
criticism. They also typically accommodate to the illness and enable its perpetuation. For example, her parents
would buy diet foods or succumb to Rose's threats that she would not eat if she is not allowed to exercise.

FIGURE 4 The formulation of interpersonal risk factors and target of family skill sharing
1410 | TREASURE ET AL.

FIGURE 5 The content of the collaborative care–skills workshop

To reduce the negative connotations that technical terms such as expressed emotion evoke in the patient and
family, animal metaphors are used. For example, kangaroo represents overprotection, ostrich with denial, and
rhinoceros with hostility. Dolphin or St. Bernard are used to describe the positive, warm parenting style which
supports recovery. “See‐saw” oscillations in care‐giving style are common within and between individuals. To
counteract this, carers are encouraged to collaborate to establish a stable, middle‐ground position without
accommodating or enabling the illness. This is achieved by psychoeducation about anorexia nervosa, including its
complex and subtle intricacies, such as its impact on social cognition and by teaching behavior change skills, as well
as skills to reduce intense interpersonal reactions potentially perpetuating the illness (for more information see
carers handbook; Treasure, Smith, & Crane, 2007).
Before treatment, Rose's father avoided dealing with her eating disorder and left most of the management to
his wife (animal metaphor: ostrich). Her mother, on the other hand, had accommodated to Rose's special rules and
rituals pertaining to food (animal metaphor: kangaroo). This fragmented approach from the parents weakened the
level of social support available for Rose and allowed disordered eating habits to be formed, entrenching the illness.
Rose's increasing malnutrition further served to accentuate her obsessive–compulsive personality and anxiety
traits. As time progressed, she became more anxious, rigid, and inflexible while her insight into her illness
decreased. These features rendered it difficult for Rose to engage with treatment. Furthermore, one can speculate
that there were secondary gains from the illness, such as a sense of mastery and control over the (shrunken)
horizons of her life.

3 | C O UR S E O F TRE A TM E N T

Rose failed to make any progress in the first few sessions of treatment. She engaged poorly and did not think the
manual was the correct approach for her. Her score on the visual analog scales of importance of change was 6.5 out
of 10, suggesting moderate motivation. She appeared at times to recognize that aspects of her life were
unsatisfactory but her confidence to change was 2.5 out of 10, that is very low. She was determined that she did
not want her weight to go above a threshold of BMI 14.0 kg/m2. She wrote long detailed explanations for this
position, whereas the written tasks from the workbook were completed in a superficial manner. She made little
TREASURE ET AL. | 1411

attempt to make changes in her behaviors and was half‐hearted about involving her parents. For example, it was
difficult to identify a suitable time for a joint meeting. The therapist explored relationships at home and asked Rose
who might help her increase her confidence to change and what they could do. However, Rose blocked the idea
that her parents could help.
On the other hand, Rose appreciated the formulation letter and recognized that the therapist had listened to
her even though they had different perspectives. She found some aspects of the workbook such as the cognitive
style interesting and was able to see that her attention to detail might have a down side.
There was a small initial improvement in her eating patterns and her weight, but this was not sustained and the
physical monitoring revealed signs of multiorgan failure. Rose's parents came to an emergency meeting to discuss
the further management of this severe health risk. The therapist explained that after the assessment, the team
members were pessimistic that outpatient care would be sufficient. However, given Rose's antipathy to inpatient
care, they had undertaken a therapeutic risk and tried to support her as an outpatient.
The therapist briefly discussed with Rose's parents in lay language how the neuroadaptive (engrained habits)
and neuroprogressive (loss of brain and body capacity because of prolonged starvation) made change difficult. The
therapist concluded that inpatient treatment was now required and there was sufficient evidence for this to be
mandated if necessary. Rose (reluctantly) and her family agreed to this. The therapist explained that although the
MANTRA individual sessions had stopped for the moment, some of the themes picked up in the formulation would
be delivered on the ward through group and individual work, focusing on cognitive remediation and emotion skill
training (Adamson, Leppanen, Murin, & Tchanturia, 2018), social mapping, and family workshops.
Rose's care plan involved meal support during inpatient treatment. Progress remained very slow and Rose
became increasingly anxious with sleep problems. She was offered a low dose of olanzapine which helped with her
rigid thinking, anxiety, and sleep difficulties. Family work focused on planning for home leave and discharge. There
were regular multidisciplinary team reviews to monitor progress.
It was clear from the family assessment that Rose's family had a divided response to her illness and participated
in many accommodating behaviors which allowed the illness to persist. A great deal of effort was therefore made to
engage both parents in treatment. They first had an individual session when the importance of social support to
facilitate Rose's transition from inpatient to outpatient care was explained. Her father emphasized two difficult
aspects of care‐giving. First, he admitted that he had difficulty conceptualizing Rose's eating difficulties as an illness.
Second, he explained how he had taken a step back to counterbalance his wife's tendency to overprotection. To
engage him into treatment, the potential positive role of fathers was emphasized, and he was given relevant reading
material. The parents were invited to a skill‐training workshop to increase their understanding of the illness and
improve their competencies to support their daughter.
Other families were also invited to these workshops which run at 1–2 monthly intervals. The workshops are led
by multidisciplinary team members and a recovered patient. More information about the workshops is available in a
revised carers handbook (Treasure, Smith, & Crane, 2016). Family members are encouraged to obtain more
information from the book and related DVDs (www.thenewmaudsleyapproach.co.uk/Home_Page.php). Figure 5
illustrates the format of the workshops, emphasizing the role of family psychoeducation about eating disorders, and
of skills training to reduce illness‐maintaining factors and enlace change‐related processes.
After the workshop, Rose's father reported that he found comfort in knowing that there were other fathers
who felt the same and asked for additional support. He found it helpful to learn techniques supporting someone
with anorexia nervosa, such as the type of language to use, and how and when to use it. Although he found the role‐
plays which focused on using a style of motivational interviewing to work on goals hard, he could appreciate their
value. He recognized that he had been saying all the wrong things, worsening the situation. He found the animal
analogies very helpful and identified himself as oscillating between ostrich and rhinoceros behaviors. He saw the
need to walk/swim (animal metaphor: dolphin or St. Bernard) alongside Rose so that he could nudge her back on
track when things got difficult.
1412 | TREASURE ET AL.

The therapist built upon this increased motivation from Rose's father and encouraged him to play a more active
role in her social rehabilitation. As they both shared a passion for physical activity, he decided to be more flexible in
his leisure pursuits and explored the possibility of reducing running and planning a more sociable form of exercise
that he could share with Rose. He made enquires and found a yoga class which was suitable for someone with
osteoporosis. He also found a choir which they both could participate in.
Both parents also began to work together, looking for the ways in which they previously accommodated the
illness in terms of food behaviors. They recognized that these routines had become strongly embedded into the
family routine. Therefore, they started to discuss more effective ways to support Rose's treatment progress during
their daily family strolls. For example, they discussed how some of the kitchen rules might be changed. The
therapist encouraged them to come up with a long list of possible change suggestions, and from these they agreed
on a joint approach to instigate small changes which they discussed with Rose. Previously, they had accommodated
to the illness by letting Rose have sole use of the kitchen to prepare her meals. This meant that they were banned
from the kitchen for 2 hr each evening. They wanted to be more flexible about this, asking whether it would be
possible for one of them to come into the kitchen to make a cup of tea during this time. The initial plan was for this
to be 2 min only, but the long‐term goal was for this time to be extended minute‐by‐minute. The long‐term goal was
to reduce these “no‐go” times and to be able to share snacks and eventually meals together.

4 | OUTCOME

Rose worked hard through her inpatient admission and her weight increased by 15%, to a BMI of just over 15 kg/m2.
She had moderated some of her obsessive–compulsive traits and became more flexible about her eating behavior in the
cooking and canteen group. Gradually, she increased her social eating on the inpatient unit and could sustain her weight
at home while adopting a more flexible approach in her eating. Rose appreciated that her parents had now “got inside
her head” and were able to listen and be willing to help her make small changes at home, while at the same time also
trying to widen her social connections.
Rose was adamant that she would not let her weight increase further than 15 kg/m2. The team indicated that
“maintaining” weight at this level was not possible, as the accumulation of starvation‐related deficits would
continue to increase. Nevertheless, they thought that the best approach for the moment would be to consolidate
the goals reached so far by working in an outpatient rather than inpatient setting.

5 | CLIN IC AL PRAC TICE A ND S UMMARY

Autistic spectrum traits are commonly seen as part of the comorbidity associated with anorexia nervosa (Koch
et al., 2015). Furthermore, these traits can become exacerbated by the starvation of the acute illness (Treasure,
2013) and add to the complexity of the illness. It is unclear whether these traits adversely affect outcome (Nazar
et al., 2018) and whether treatment should be adjusted to cater for the specific needs of these individuals.
Starvation produces autistic‐like features, exacerbating obsessive–compulsive traits, and reducing social cognition.
Thus, the general treatment principles are applicable to most cases of anorexia nervosa. However, the degree of
recovery after weight gain will vary and so the goals and degree of support may need to be adjusted. The present
description illustrates how a case formulation can be used to guide treatment. Given the severe and enduring form
of the illness, it is understandable in this case that a more intense form of treatment was needed. The addition of
skills‐based workshops is a useful means to inform close others about the nature of the illness and how it becomes
entangled with automatic processes in the brain. Careful planning for reasonable goals is therefore needed. When
carers put their unrealistic expectations aside and can work as a team with a coherent approach, they become less
frustrated and more effective at providing support. It is interesting that fathers often comment that improving skills
TREASURE ET AL. | 1413

in communication and facilitating behavior change are useful tools that they can generalize to other settings.
Furthermore, patients often report that their fathers are particularly proficient at implementing change plans
suggested by the therapist.
The implementation of a skills‐based workshop described in this report is one option to include parents in the
treatment of their ill children. Skills‐based workshop is usually geared for adult patients, sometimes with a severe
and enduring form of the illness, although adolescent patients with eating disorders can be treated with this
method. Other forms of parental involvement in the treatment of patients with eating disorders also exist. For
example, the skills‐based intervention has been given as a form of guided task‐sharing and was found to reduce
hospital readmissions following inpatient care for adults (Hibbs et al., 2015; Magill et al., 2016), with a small
reduction in “rescue” inpatient treatment for adolescents (Hodsoll et al., 2017).
Another common approach in eating disorders to involve family is family‐based treatment (FBT; Le Grange
et al., 2016). In contrast to the parental counseling module in MANTRA which emphasizes the role of the parents to
reduce illness‐maintaining factors and enhance health‐related processes, FBT aims toward empowering the parents
to play an active and positive role to restore the weight of their ill children. Not surprisingly, FBT is recommended
for young adolescents with a relatively short‐term illness, in contrast to the parental module of the MANTRA,
mainly used in adult patients who sometimes have a more protracted course. This highlights the importance of
tailoring the specific treatment for the specific patient, taking into consideration also the specific stage of the illness
that the patient is currently facing (Treasure, Stein, & Maguire, 2015).

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How to cite this article: Treasure J, Schmidt U, Kan C. An illustration of collaborative care with a focus on
the role of fathers in Maudsley Anorexia Nervosa Treatment for Adults (MANTRA). J. Clin. Psychol. 2019;75:
1403–1414. https://doi.org/10.1002/jclp.22789